Child Enrollment and Health Information

State of Ohio Form JFS-01234
This form must be completed for all students.
Instructions: Please complete this form in its entirety. If you are presented with a question that doesn't apply to you, simply type NA in it (for not applicable) so we know you read it.  Thanks.

About Your Child

Which program is your child enrolled in?
Please select one. *
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Parent/Guardian Information (1)

Parent/Guardian 1 should be the parent filling out the form, who will receive the confirmation email.
Home Telephone same as Child's? *
Home Address same as Child's? *
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other parents/guardians. *
Please indicate which number(s) above to include on the list. (check all that apply) *

Parent/Guardian Information (2)

Parent/Guardian 2 - please complete or enter NA in each field if not applicable to your family situation.
Home Telephone same as Child's? *
Home Address same as Child's? *
Please indicate if this name should be released if a parent/guardian, of a child attending the center/home, requests contact information for other parents/guardians. (check one) *
Please indicate which number(s) above to include on the list. (check all that apply) *
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Emergency Contacts

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Contact 1 (Required)
Contact 2

Physician Information

Allergies

Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home.
Does your child have any food, medication or environmental allergies? (check one) *
Please check all allergies that apply *
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Does your child's allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child? (check one) *

Special Health or Medical Conditions

Does your child have a developmental delay or special health or medical condition? (check one) *
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Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours? (check one) *

Medication or Medical Food

Is your child currently using any medication or medical food? (check one) *
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Does this medication or medical food need to be administered at the child care program/home? (check one) *

Dietary Restrictions

Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one) *
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Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group? (check one) *

Hospitalization and Health Concerns

List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation. *
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Additional Details

List any additional information about your child that would be useful for staff to know, such as fears or ways your child prefers to be comforted. *
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List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits. *
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List any additional information about your child that would be useful for staff to know, such as special routines, or behavior needs. *
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Diapering Statement

If your child toilet trained? (check one) *
Please contact the director as all children are required to be potty trained for this program. Thanks.

Emergency Transportation Authorization

Because the safety of your child is of uptmost importance to us, UALC Preschool and Kindergarten requires that the parent authorize us to transport your child in case of an emergency.
Permission to Transport (check box) *
UALC Preschool and Kindergarten has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency trasnportation service will determine the facility to which my child will be transported.
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Acknowledgement of Policies and Procedures

I have reviewed and received a copy of the program's or home's policies and procedures/handbook. (check one) *
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care. 
 
By typing in your name and date, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
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This is a prescribed form which must be used by child care providers to meet the requirements to rules 5101:2-12-15, 5101:2-13-15, and 5101:2-14-04. This form must be on file at the program or home on or before the child's first day of attendance and thereafter while the child is enrolled.
JFS 01234 (Rev. 10/2021)
 
JFS 01234